Subspecialty Section
Amputation after trauma Jowan Penn-Barwell
Jowan Penn-Barwell is a Consultant Orthopaedic Trauma Surgeon in the Royal Navy and is the Clinical Lead of the Oxford Trauma Service. His research interests include ballistic trauma, outcomes after complex limb injuries and evaluating novel limb salvage techniques.
Surgical amputation following an injury is rare, and consequently few surgeons perform them frequently in this context. Overall, only around 5-15% of lower limb amputations are performed following injury, with the majority being due to vascular disease1,2. Reference texts and the literature mainly focus on dysvascular limb loss patients who are typically older, sicker and with less potential for rehabilitation than the trauma patient, which limits their utility to the trauma surgeon.
T
he aim of this article is to provide the reader with an overview of the difficult decisions that have to be made when contemplating and planning lower limb amputation after trauma, and place them in the context of current literature and understanding.
Initial surgical treatment of severe limb injury Severe limb injury frequently occurs in the context of polytrauma. In these instances, initial treatment should be focused on the techniques of damage control resuscitation and surgery: haemorrhage control, tailored resuscitation with blood products and skeletal stabilisation. Decision making around limb viability is extremely challenging in the context of surgery. Immediate completion of partial amputation is normally only necessary when the patient is in physiological extremis.
“Surgeons may be tempted to rely on scoring systems such as MESS to aid decision making; at least six systems have previously been proposed to quantify limb injury and identify those which are potentially viable and those in which salvage attempts would likely be futile.�
Surgeons may be tempted to rely on scoring systems such as MESS to aid decision making; at least six systems have previously been proposed to quantify limb injury and identify those which are potentially
54 | JTO | Volume 08 | Issue 04 | December 2020 | boa.ac.uk
viable and those in which salvage attempts would likely be futile3-8. The studies presenting these scoring systems share similarities: they are cohort studies of limb-threatening trauma, the presumptive treatment was salvage, and regression analysis was used to determine predictive factors that form the basis of the scoring systems they propose. These scoring systems have been shown to be poor predictors of limb viability in both the civilian9 and military context10, and do not adapt as techniques and therapies improve. In the absence of an algorithmic basis for decision making, surgeons must rely on a subjective process based on their experience and unit capabilities. If possible, severely traumatised limbs should be carefully examined pre-operatively by senior orthopaedic and plastic surgeons, photographed, and imaged using CT angiography in accordance with NICE11 and BOAST guidance12. Surgeons should postpone any absolute decisions about amputation until the limb has been fully assessed intra-operatively and crucially all non-viable or irredeemably contaminated tissue has been excised. This systematic excision or debridement may in fact involve a de-facto amputation.
